Integrating Your Skills

As patients are becoming more educated, involved and interested in their own health care, the demographics and strategies of the health care industry are evolving. Health care is trending toward a focus on prevention, wellness and treatment of the whole person. Integrative health in the acute care setting focuses on optimizing the body’s natural healing capacity, empowering patients to be collaborative partners in their own care, and providing patients with education and tools for exercising self-care skills after they are discharged from the hospital.

Integrative health is emerging as an innovative strategy to increase patient satisfaction, decrease frequency/length of stay, increase patient resilience, and reduce many of the common complaints associated with hospitalizations, such as pain, stress, anxiety, nausea/vomiting, constipation and trouble sleeping. For example, a pain management study recently completed by the Integrative Health Research Center at the Penny George Institute for Health and Healing (the George Institute), in Minneapolis, Minnesota, showed that integrative care services reduced self-reported pain by more than 50 percent in 1,837 hospitalized patients (Dusek, Finch, Knutson and Plotnikoff, 2010).

The benefits of integrative health services in the acute care setting can result in significant cost savings for hospitals and insurance companies. As a result, integrative health is being explored as a core initiative, mission and model of care in some of the nation’s top health care organizations. The advancement of integrative care is fueling a demand by acute care hospitals and clinics for integrative health practitioners who are cross-trained in multiple mind-body modalities.

And that’s where you, the massage therapists, come in.

A Day in the Life

Unlike other massage therapy environments where clients seek out services, at Abbott Northwestern hospital, integrative health practitioners seek out patients—usually in response to referrals from nurses, physicians and other health care providers, and often in response to patient or family request.

Here is how this referral process works: A nurse or physician requests integrative health services for a patient using the same system they would if they were to request a neurology or physical therapy consultation. Nurses or physicians enter a consultation request in the patient’s electronic medical record system and the referral automatically prints out on a computer in the Integrative Health department, where it’s then triaged by the integrative health team.

To streamline the referral process, the integrative health care team at Abbott Northwestern hospital developed specific referral criteria. The criteria include pain, anxiety, stress, nausea/vomiting, elimination problems, insomnia, coping with changes in health and well-being, and maintaining or prolonging a pregnancy.

Doing Rounds

Practitioners arrive to work at 8 a.m. and begin the day with a ‘blessing’ created by, and for, the team to ground, center and unite the team, as well as set positive intentions for the patients and the work. The number of practitioners actually seeing patients varies from approximately six to 15, depending on individual schedules, indirect patient care responsibilities (educational programming, meetings, and program development and research initiatives) and other patient services (group art classes, group acupuncture).

Practitioners begin rounds at 8:30 a.m., where the team discusses the assignment of ongoing patients, triages new referrals, and prioritizes and assigns new patients to the most appropriate practitioner based on expertise and availability. Each practitioner acts as a care coordinator for a number of patients and, in collaboration with the patient and other health care providers, develops a plan of care for each patient.

Rounds are typically finished at 9 a.m. Practitioners then begin working in various departments of the hospital doing patient assessments, treatments, charting and communicating with other care providers.

Patient Assessment

Prior to providing a treatment intervention with a patient, practitioners spend approximately 30 minutes completing an assessment that involves reviewing the patient’s electronic medical record, communicating to the patient’s primary care providers, completing a formal face to face assessment, and gathering nonverbal/nonwritten information from sources like a patient’s body language.

Myriad factors are taken into consideration, such as diagnosis, platelet level, quality of coagulation, acute infection, level of acuity and consciousness, contact precautions, cognitive impairment, medications, skin quality, level of activity, general health history, as well as mental, emotional and psychological well-being. Practitioners also assess how committed patients are to actively participating and engaging in their healing process, and how ready they are to change.

Combined, all of this information, along with professional judgment, critical thinking, ethics, values and compassion, allows practitioners to assess how integrative health might support a patient’s wellness goal. During the intake process with a patient, practitioners assess and articulate the values, beliefs and purpose of integrative health, help patient’s set goals and collaboratively create a specific plan of care for the role integrative health care can play in the patient reaching these goals.

Collaboration and teamwork are core principals to both patient care and practitioner resilience. Collaboration with hospital staff is a key component of the work, involving direct communication with hospital staff. You will need to document work flow, as well as a patient’s progress and plan of care in the hospital’s electronic medical record system. Similar to nurses and other hospital care providers, the team of integrative health practitioners works closely with one another in patientrounds and throughout the day to coordinate patient care. Given the lack of acute-care training in the current academic arena, most massage therapists currently have little or no experience or training working in the hospital care setting, so teamwork has been a critical component to practitioner and program development.

The massage therapy team and larger integrative health team meet on a regular basis to discuss scope of work, approach, refinement of policies and procedures, practitioner resilience, conflict resolution, communication, language barriers, documentation, research, education, and the overall growth of the discipline within and beyond the walls of the hospital. Meeting the demands of patient care and the growing program is an exciting and delicate balancing act.

Putting the Plan in Motion

Based on the assessment, a practitioner determines what modalities might be appropriate and how a particular modality(s) might be modified to accommodate each unique patient. The practitioner then provides a holistic integrative health intervention, which typically involves a unique combination of a variety of modalities, including massage therapy, reflective listening, healing touch, guided imagery, aromatherapy, patient education, breathing, music therapy, oriental medicine, reflexology and art care, to name a few. Treatment interventions typically last anywhere from 20 minutes to one hour, depending on the type of intervention and what unfolds for a patient during a particular session. Often, too, patients are unavailable, so practitioners may have to make several attempts before actually working with a patient.

Practitioners undergo significant training in compliance with hospital standards, procedures and protocol (such as patient safety, universal precautions, security and emergency preparedness). During each treatment, practitioners consider potential contraindications, patient safety measures and appropriate precautions (use of gloves, gown and mask when indicated). Practitioners become familiar with a variety of illnesses, diagnoses and symptoms, as well as how specific interventions may be indicated, contraindicated or appropriately modified (such as using lighter pressure when applying therapeutic massage to a patient on blood thinning medication).

The number of integrative health sessions a particular patient receives depends on the length of hospitalization, the timing of the referral and the patient’s progress. Some patients receive a number of sessions over a long period of time, such as high-risk pregnant women on long-term bed rest, patients undergoing intensive rehabilitation, and those who are waiting for (and eventually undergoing) heart transplant procedures. Others, such as patients undergoing minor surgery, may only be seen once or twice.

Services are discontinued if a patient’s goals are met or if a patient is discharged. If patients show no progress or are not invested in the treatment, services may also be discontinued. Additonally, a patient may be discontinued if their status changes with respect to cognitive ability, level of acuity or state of consciousness. A patient’s status and progress can change daily—sometimes hourly—so the assessment process is ongoing and essentially allows practitioners to prioritize care and discontinue care at the appropriate time.

Integrative heath practitioners are in a unique position to simply be present with patients. Your presence can allow a patient to feel heard, witnessed and supported. Integrative health practitioners are nonjudgmental creators of a safe space. While practitioners cannot know the enormity and depth of a patient’s feelings or experience, they can be honored by, and committed to, the role of being an unwavering presence in the midst of it. Often, too, the rapport and connection that is established through relationship-centered care creates a safe space for a patient to reflect on and process the emotional meaning of their physical medical experience, as well as their intentions for moving forward with respect to health and wellness.

Creating a relaxing space in the midst of the anxietyprovoking hospital environment can be challenging, however. Hospital rooms often have bright fluorescent lights, medical equipment, hospital beds, intravenous medications, and interruptions by family, friends and other health care providers. Aromatherapy, dim lights and access to the hospitals “care channel,” which broadcasts relaxing music and scenery, can be helpful. Relationship-centered care creates a sacred circle between the practitioner and the patient; it is this environment that holds the possibilities for healing.

Communication and Teamwork

After each treatment, practitioners spend approximately 15 minutes charting progress notes, qualitative and quantitative data, work flow and the patient’s plan of care in the hospital’s electronic medical records system. Electronic charting documents the details and impact of each treatment intervention and communicates information to other care providers about a patient’s treatment plan. Electronic charting is not a replacement for the important face to face communication and collaboration between integrative health practitioners and other members of a patient’s treatment team.

When feasible and appropriate, practitioners chart a patient’s self-reported ratings on pain, anxiety/stress, nausea and well-being prior to—and immediately following—an intervention. The Integrative Health Research Center at Abbott Northwestern Hospital uses this electronic data to communicate the efficacy of integrative health for reducing many of the common complaints associated with hospitalizations, such as pain, stress, anxiety, nausea/vomiting, constipation and trouble sleeping. The data is used by the research center to show how integrative care is impacting patient satisfaction, pain management, length of stay and total hospital charges.

Each practitioner also spends a couple minutes each day documenting their productivity in an internal database. This database communicates information on how a practitioner’s time is divided between direct patient care, indirect patient care, administrative responsibilities, and research and program development initiatives.

Collaboration and teamwork are also core principals to providing integrative health care in an acute care setting. Similar to nurses and other hospital care providers, the team of integrative health practitioners works closely with one another in morning rounds and at the end of the day to coordinate patient care. Practitioners typically spend the last half hour of the day (between 4:00 and 4:30) creating a plan of care for each patient and collaborating with other integrative health practitioners about their potential involvement in a patients plan of care.

For example, if a massage therapist believes acupuncture may support a patient’s pregnancy, they would communicate with the acupuncturist and coordinate the inclusion of an acupuncture assessment in a patient’s plan of care. The acupuncturist or massage therapist would also coordinate with the nurse or physician to obtain a specific referral for acupuncture (acupuncture is the only integrative health treatment considered invasive and requires a separate physician-approved referral request).

It is an honor and privilege to work with patients at such critical and often transformational times in their lives. Patients are often acutely ill, facing difficult diagnoses, stressful decisions, anxiety-provoling procedures, painful recoveries and life-changing experiences. The strength, resilience, depth and wisdom of the human spirit at times like these is profoundly moving and inspiring.

While intense and often exhausting, the work is professionally and personally fulfilling to say the least. In order to be an authentic, effective and healing presence as a patient moves through their hospital experience and healing journey, however, practitioners must be in a relatively balanced and healthy space themselves. Self-care, personal awareness and healthy boundaries are essential to being a resilient and effective practitioner.

In the context of health care, hospitals, clinics, care providers, educational institutions, health care organizations, private insurers, public program administrators, and public policymakers are looking for solutions to manage pain (and other symptoms), increase patient satisfaction, decrease length of stay and costs, and increase quality of care. Integrative health in the acute care setting is a transformational tool for creating a sustainable model of mind-body-spirit wellness both for the individual and for the health care system as a whole. As the discipline grows, so will the opportunities for massage therapists to work in this exciting new environment.

The Future

To meet the increasing demand for integrative health practitioners, the George Institute is launching a weeklong continuing education course “Integrative Health Practitioner Training Program for Massage Therapists,” offering its first session in September 2010. The program will familiarize therapists with approach and scope of working within an acute care setting. Topics will include: patient assessment and care coordination, psychoneuroimmunology, evidenced-based practice, practitioner resilience, documentation, compliance, indications/contraindications and research. Students will also become familiar with the various modalities, techniques and cultural skills in the hospital setting through lecture and creative experiential learning.

The Penny George Institute

With more than 57 integrative health professionals, the Penny George Institute, founded by the George Family Foundation and the Ted and Dr. Roberta Mann Foundation, is the largest hospital-based integrated health program in the nation. In addition to its comprehensive inpatient program, the Penny George Institute boasts a state-of-the-art outpatient clinic, a hospital-based fitness center, an integrative health research center, and extensive educational programming for patients, health care professionals and members of the community.

In the institute’s first five years, 23 integrative health practitioners provided more than 60,000 therapeutic intervention sessions with patients hospitalized at Abbott Northwestern Hospital in Minneapolis, Minnesota. Practitioners provide a wide range of services, including therapeutic massage, at the patient’s bedside. Practitioners work in most areas of the hospital, including cardiovascular, rehab, ortho/spine, neurology and womencare. Through the hospital’s electronic charting system, practitioners receive referrals (or requests for services) from nurses, physicians, social workers, chaplains, patients or family members.

An Example Of Integrative Health Care at Work: The Birth Experience

Four of the George Institute’s integrative health practitioners specialize in providing therapeutic interventions for antepartum, preoperative, laboring and postpartum women. In addition to core training in oriental medicine, therapeutic massage or advanced practice nursing, each integrative health practitioner working in the womencare unit is cross-trained in various modalities such as guided imagery, aromatherapy, energy work and other mind-body skills.

Practitioners meet with patients prior to scheduled cesarean births to reduce anxiety, for example. On occasion, practitioners have accompanied patients into the operating room to relieve anxiety, helping the surgery proceed smoothly and benefiting the physician, anesthesiologist and nurses as much as the patient. During labor, practitioners provide mind-body-emotional support modalities and offer a calm and reassuring presence.

Postpartum interventions often focus on pain reduction, and providing patient education and skills to improve sleep, manage stress/anxiety, enhance well-being and strengthen bonds with baby. On occasion, integrative care entails the delicate and complicated role of supporting parents as they experience the expected or unexpected loss of their infant(s).

A major goal of the womencare team has been to prolong pregnancy for antepartum patients hospitalized for complications by reducing pain, stress, anxiety, nausea, constipation and insomnia. Antepartum patients may have difficulty coping with a wide range of emotions that emerge. For example, a patient might feel: scared about their health and the health of their baby; a loss of control over their life, their pregnancy and their body; anger and disappointment regarding their loss of their ideal, uncomplicated pregnancy; isolated from family and friends; or resistant to bonding with an expectant baby, especially if there is a history of a previous loss.

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